Participation in cancer screening programmes

Main topic
English version of “Inanspruchnahme von
Krebsfrüherkennungsuntersuchungen.
Ergebnisse der Studie zur Gesundheit
Erwachsener in Deutschland (DEGS1)”
Bundesgesundheitsbl 2013 · 56:858–867
DOI 10.1007/s00103-012-1655-4
© Springer-Verlag Berlin Heidelberg 2013
A. Starker · A.-C. Saß
Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin
Participation in cancer
screening programmes
Results of the German Health Interview and
Examination Survey for Adults (DEGS1)
Background and purpose
Cancer is responsible for a great proportion of mortality and disease burden in
the population. In 2010, cancer accounted
for 26.2% of all cases of death in Germany,
making it the second most common cause
of death (after cardiovascular diseases at
41.1%) [1]. As cancer is increasingly common later in life, demographic changes
mean that certain types of cancer increase
with the growing proportion of the elderly [2]. On the other hand, cancer mortality rates (age-standardised death rates) are
decreasing overall, and the chances of survival for cancer patients have significantly
improved in recent decades. This is largely due to the progress made in cancer therapy but also to the early detection of cancer [3]. The aim of cancer screening tests
is to detect the disease at the earliest possible stage. This permits early commencement of a suitable therapy and hence gentle treatment with a better chance of success. Screening tests for common types of
cancer have been offered as part of statutory health insurance for over 30 years.
The cancer screening services target ageand sex-specific groups in which the relevant types of cancer are more prevalent.
Statutory health insurance currently covers screening for cervical cancer, breast
cancer, prostate cancer, colon cancer and
skin cancer [4].
The World Health Organization
(WHO) has defined criteria and guidelines for screening tests [5]. Based on these
criteria, statutory health insurance on-
ly covers screening tests if effective treatment for the relevant type of cancer exists
and if it can be unequivocally diagnosed
in the development or early disease stage
by means of diagnostic measures. Furthermore, sufficient physicians and facilities must be available to secure the diagnosis and carry out the treatment [6].
From population-related surveys and
the payment data of health insurers, it is
known that a growing number of people
in Germany are not only aware of the existing cancer screening services but also participate in them. However, it is
still the case that only part of the population is reached. Age, sex, the level of education/socioeconomic status, partnership, children, health condition and utilisation of GP health care services [7, 8, 9,
10] are seen as determinants that can influence the extent to which screening programmes are used. For the success of cancer screening programmes—in terms of
reducing the disease burden and mortality
at the population level—awareness, acceptance and willingness to undergo cancer
screening tests are decisive factors within
the various target groups.
The aim of the current analysis is to
provide an overview of the awareness,
knowledge and participation in cancer
screening programs within the German
population and to discuss possible influencing factors. For this purpose, data from
the first wave of the “German Health Interview and Examination Survey for
Adults” (DEGS1) conducted by the Robert
Koch Institute (RKI) were analysed. The
focus was on the types of cancer screening that are offered to men and women by
statutory health insurance.
Methods
The “German Health Interview and Examination Survey for Adults” (DEGS) is
part of the health monitoring system at
the Robert Koch Institute (RKI). The concept and design of DEGS have been described in detail elsewhere [11, 12, 13, 14,
15]. The first wave (DEGS1) was conducted between 2008 and 2011 and comprised
interviews, examinations and tests [16,
17]. The target population comprises the
residents of Germany aged 18–79 years.
DEGS1 has a mixed design that permits
both cross-sectional and longitudinal
analyses. For this purpose, a random sample from local population registries was
drawn to complete the participants of the
“German National Health Interview and
Examination Survey 1998” (GNHIES98)
who re-participated. A total of 8,152 persons participated, including 4,193 firsttime participants (response rate 42%) and
3,959 revisiting participants of GNHIES98
(response rate 62%). In all, 7,238 persons
attended one of the 180 examination centres, and 914 were interviewed only. The
net sample (n=7,988) permits representative cross-sectional analyses and time
trend analyses to be performed for the age
range of 18–79 years in comparison with
GNHIES98 (n=7,124) [15]. The data of the
revisiting participants can be used for longitudinal analyses.
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
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Main topic
Tab. 1
Cancer screening tests offered by statutory health insurance and covered by DEGS1. (Joint Federal Committee [4])
Goal of cancer screening
Type of examination
Target group
Age
Examination interval
Early detection of skin cancer
Early detection of colon cancer
Whole-body skin examination
Stool examination (rapid test for occult, i.e. hidden,
blood in the stool)
Women, men
Women, men
Colonoscopy
Women, men
From 35 years
From 50 to 54 years
From 55 years
From 55 years
Cervical smear test
Breast palpation
Mammography as part of the national mammography screening programme
Prostate palpation (digital rectal examination)
Women
Women
Women
From 20 years
From 30 years
From 50 to 69 years
Every 2 years
Annually
Every 2 years
Two colonoscopies at
an interval of 10 years
Annually
Annually
Every 2 years
Men
From 45 years
Annually
Early detection of cervical cancer
Early detection of breast cancer
Early detection of prostate cancer
Awareness of the recommendations of statutory health insurance regarding participation in cancer screening, categorised by sex, age
groups and socioeconomic status (proportion in percent with 95% confidence intervals)
Tab. 2
Sex
Socioeconomic status
Wom- Total
en
Low
Medium
High
Men
Total
Low
Medium
High
Total
Age group in years
18–29
30–39
40–49
50–59
60–69
70–79
Total
74.0 (69.8–77.9)
61.2 (50.8–70.7)
76.6 (71.2–81.3)
84.0 (70.6–91.9)
45.2 (40.5–50.0)
40.0 (29.0–52.1)
43.6 (38.1–49.3)
59.5 (45.5–72.1)
59.2 (55.8–62.5)
78.8 (73.8–83.0)
51.7 (34.2–68.7)
82.1 (75.9–86.9)
89.3 (83.3–93.3)
62.4 (56.2–68.1)
40.2 (26.8–55.3)
64.7 (56.4–72.1)
75.7 (66.3–83.2)
70.5 (66.2–74.5)
91.0 (87.4–93.6)
76.4 (62.4–86.4)
94.6 (91.4–96.7)
92.7 (86.4–96.2)
79.5 (74.5–83.7)
65.8 (51.6–77.6)
82.4 (76.2–87.3)
83.4 (75.5–89.1)
85.1 (81.6–88.0)
96.8 (95.2–97.9)
91.6 (83.9–95.8)
98.3 (96.6–99.1)
97.3 (93.3–98.9)
91.2 (88.2–93.4)
84.4 (75.8–90.4)
92.1 (88.2–94.8)
94.2 (89.5–96.9)
94.0 (92.4–95.3)
98.0 (96.3–98.9)
96.6 (91.8–98.6)
98.3 (96.4–99.2)
98.4 (91.9–99.7)
92.9 (90.4–94.8)
91.9 (85.1–95.8)
91.6 (87.6–94.4)
96.5 (93.2–98.2)
95.5 (94.0–96.6)
93.6 (90.3–95.8)
88.2 (81.5–92.7)
96.1 (92.4–98.1)
100 (100.0–100.0)
92.3 (89.6–94.4)
88.7 (78.6–94.4)
92.8 (89.0–95.1)
96.8 (92.5–98.6)
93.0 (91.0–94.7)
88.5 (87.0–89.9)
78.8 (74.3–82.8)
91.0 (89.4–92.4)
92.7 (89.9–94.8)
75.7 (73.6–77.8)
66.7 (61.6-71.5)
75.8 (72.9–78.5)
84.3 (80.8–87.3)
82.2 (80.7–83.5)
nunweighted =6,839
The cross-sectional and trend analyses are carried out with a weighting factor that corrects deviations in the sample
from the population structure (as of 31
December 2010) with regard to age, sex,
region and nationality, as well as community type and education [15]. A separate weighting factor was prepared for
the examination part. Calculation of
the weighting factor also considered the
re-participation probability of the GNHIES98 participants, based on a logistic regression model. For the purpose of
conducting trend analyses, the data from
GNHIES98 were age-adjusted to the population level as of 31 December 2010. A
non-response analysis and a comparison
of selected indicators with data from census statistics indicate a high level of representativity of the net sample in the resident population of Germany aged 18–
79 years [15].
To take into account both the weighting as well as the correlation of the participants within a community, the confidence
2 |
intervals were determined with SPSS-20
procedures for complex samples. Differences were regarded as statistically significant if the respective 95% confidence intervals did not overlap.
For the analyses of participation in
cancer screening, information from the
computer-assisted personal interview
(CAPI) was used (n=7,988). In this interview, participants were asked whether
they are aware that participation in cancer screening is recommended by health
insurers and whether they regularly undergo such screening. They were then
asked whether they had ever undergone
screening for cancer in specific locations.
If the answer was yes, participants were
asked when the last screening test had
taken place. Participants had a choice of
five possible answers: time periods from
“within the last 12 months” to “more than
10 years ago”. With these answer categories, it was possible to assess whether the last specific cancer screening test
was conducted within the recommend-
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
ed examination interval. This aspect is
the focus of the analysis presented here.
The information on participation in the
various cancer screening tests (presented
in . Tab. 1) was collected in DEGS1 and
subsequently analysed.
Additionally, in DEGS1, men from the
age of 45 years were asked whether they
had undergone a so-called PSA test within the specified time periods. This test to
determine the prostate-specific antigen
(PSA) is not included in the services offered by statutory health insurance for the
early detection of prostate cancer, since
there is still international controversy surrounding the test [18].
The descriptive analyses are limited in
each case to the various age- and sex-specific groups of participants. This results in
different sample sizes for the individual
questions. Additionally, the associations
between the variables age, sex and socioeconomic status (SES) were investigated.
SES was determined using an index that
includes information on school education
Abstract · Zusammenfassung
and vocational training, professional status and net household income (weighted
by household needs) and which enables
a classification into low-, medium- and
high-status groups [19].
Results
Awareness of the
recommendations of statutory
health insurers to participate
in cancer screening
In all, 88.5% of women and 75.7% of men
interviewed were aware of the recommendations of statutory health insurers
regarding participation in cancer screening programmes. The percentage of women and men who are aware of these recommendations increased with age (up
to 69 years). Younger women and men
in particular are not aware of the screening services offered. A social gradient was
noted in the level of awareness in women of the age groups up to 59 years. The
proportion of women who are aware of
these recommendations is significantly lower for women with low SES than
it is for those with medium or high SES
(. Tab. 2).
Regularity of participation
in cancer screening
According to the survey, 67.2% of women (from the age of 20 years) and 40.0%
of men (from the age of 35 years) regularly participate in cancer screening
(. Tab. 3). Another 16.2% of women
and 19.2% of men also undergo cancer
screening tests but only irregularly (data not shown). Among men, the proportion of regular participants increases with age (up to 69 years). For women,
the proportion of regular participants
increases up to the age of 59 years and
peaks between 50 and 69 years. In this
age group, over three quarters of women indicated that they participate regularly in cancer screening. It should be
noted that this age group is also the target group of the national mammography
screening programme, i.e. women who
are invited for cancer screening regularly
every 2 years. With the exception of 50to 69-year-old women, the proportion of
Bundesgesundheitsbl 2013 · DOI 10.1007/s00103-012-1655-4
© Springer-Verlag Berlin Heidelberg 2013
A. Starker · A.-C. Saß
Participation in cancer screening programmes.
Results of the German Health Interview and
Examination Survey for Adults (DEGS1)
Abstract
A growing number of people in Germany
participate in the cancer screening services offered by statutory health insurance. Using data from the first wave of the German
Health Interview and Examination Survey for
Adults (DEGS1), current levels of participation in cancer screening services were determined. DEGS1 (2008–2011) permits representative cross-sectional analyses to be performed. In DEGS1, persons who were entitled
to different cancer screening services were interviewed on their awareness, participation
and regular utilisation of cancer screening
for different types of cancer. Overall, 67.2%
of women and 40.0% of men participate regularly. Participation rates fluctuate to a great
extent for individual types of cancer screening. Women participate in cancer screening
more frequently than men do. For women, a
better socioeconomic status was associated
with higher participation rates. Participation
rates improve with increasing age, meaning that the difference in participation rates
between women and men becomes smaller. The current analyses present information
on specifically targeted population groups
to promote informed decision-making about
cancer screening, so that participation rates
can be improved further. The analyses thus
provide an important basis for health policy measures.
Keywords
Health survey · Cancer screening · Colon
cancer · Breast cancer · Prostate cancer
Inanspruchnahme von Krebsfrüherkennungsuntersuchungen.
Ergebnisse der Studie zur Gesundheit
Erwachsener in Deutschland (DEGS1)
Zusammenfassung
Eine wachsende Zahl von Menschen in
Deutschland nimmt die von der Gesetz­
lichen Krankenversicherung angebotenen Krebsfrüherkennungsuntersuchungen (KFU) in Anspruch. Mit Daten der ersten
Erhebungs­welle der Studie zur Gesundheit
Erwachsener in Deutschland (DEGS1) wurden aktuelle Inanspruchnahmeraten ermittelt. DEGS1 ist ein bundesweiter Befragungsund Untersuchungssurvey (2008–2011), der
repräsentative Querschnittsanalysen dazu ermöglicht. In DEGS1 wurden die jeweils­
anspruchsberechtigten Personen zur Kenntnis, Regelmäßigkeit sowie zur turnusmäßigen Inanspruchnahme von KFU für einzelne
Krebsarten befragt. Regelmäßig gehen ins­
gesamt etwa 67,2% der Frauen und 40,0%
der Männer zur KFU. Bei den einzelnen Unter-
those who regularly participate in cancer screening is significantly higher for
women with a high SES than for women
with a low SES. For men, participation in
cancer screening does not show any social gradient.
suchungen schwanken die Teilnahmeraten
stark. Frauen nehmen an vielen KFU häufiger
teil als Männer, und eine bessere sozioökonomische Lage war bei ihnen mit höheren Teilnahmeraten assoziiert. Im Alter verbessern
sich die Teilnahmeraten und nähern sich
zwischen den Geschlechtern an. Die Auswertungen geben Hinweise auf Bevölkerungsgruppen, die gezielt angesprochen und darin
unterstützt werden sollten, eine infor­mierte
Entscheidung zur KFU zu treffen, um die Teilnahmeraten weiter zu erhöhen. Sie stellen
damit eine wichtige Grundlage für gesundheitspolitische Maßnahmen dar.
Schlüsselwörter
Gesundheitssurvey · Krebsfrüherkennung ·
Darmkrebs · Brustkrebs · Prostatakrebs
Participation in special
cancer screening tests
Early detection of skin cancer
In all, 25.8% of women and 22.9% of men
aged 35 years and older underwent a
whole-body examination of their skin for
skin cancer screening within the 2 years
before the interview (. Tab. 4). For men,
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
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Main topic
Regular participation in cancer screening tests, categorised by sex, age groups and socioeconomic status
(proportion in percent with 95% confidence intervals)
Tab. 3
Sex
Women
Socioeconomic Age groups in years
status
Total
Low
Medium
High
Men
Total
20–29
30–34
35–39
40–49
50–59
60–69
70–79
Total
50.0
(44.5–55.6)
37.8
(26.2–51.0)
49.5
(42.7–56.3)
67.7
(54.5–78.6)
–
65.8
(57.4–73.3)
38.2
(17.0–65.0)
66.0
(54.8–75.7)
85.2
(74.4–91.9)
–
50.0
(44.5–55.6)
65.8
(57.4–73.3)
71.8
(64.4–78.0)
44.6
(23.6–67.7)
73.2
(65.1–79.9)
85.5
(75.7–92.2)
10.1
(6.2–16.0)
5.3
(0.7–29.9)
9.4
(5.0–16.8)
14.2
(7.7–24.7)
40.4
(35.3–45.8)
73.5
(69.4–77.1)
52.1
(39.8–64.1)
75.6
(70.7–79.9)
86.5
(79.9–91.1)
24.0
(20.3–28.1)
14.9
(9.0–23.7)
25.6
(20.4–31.5)
25.8
(20.0–32.6)
48.3
(45.2–51.4)
76.3
(72.8–79.5)
68.4
(56.1–78.6)
77.7
(73.1–81.6)
79.9
(72.0–86.0)
46.9
(42.4–51.4)
37.7
(27.5–49.2)
48.4
(42.5–54.4)
51.8
(43.2–60.4)
61.6
(58.6–64.5)
76.0
(72.2–79.5)
66.2
(55.2–75.7)
80.5
(76.5–83.9)
73.4
(63.7–81.3)
58.5
(54.0–62.9)
49.6
(37.9–61.3)
59.7
(53.1–66.0)
63.1
(55.2–70.4)
67.4
(64.4–70.4)
53.2
(48.1–58.2)
41.9
(32.6–51.8)
58.5
(52.6–64.2)
67.3
(53.4–78.6)
57.2
(52.1–62.2)
50.0
(38.0–61.9)
58.5
(51.5–65.1)
67.2
(57.5–75.6)
55.0
(51.2–58.7)
67.2
(65.3–69.0)
51.0
(46.4–55.6)
69.9
(67.4–71.6)
79.4
(76.0–82.4)
40.0
(37.5–42.5)
33.3
(27.8–39.4)
41.6
(38.5–44.8)
42.3
(38.3–46.4)
55.5
(53.8–57.2)
Low
Medium
High
Total
nunweighted =4,137
the proportion increases with age. Among
women, there are hardly any differences
with regard to age groups. The sex difference in the elderly is remarkable: The
proportion of 60–69- and 70–79-year-old
women who used the early detection of
skin cancer is lower than for men. There
is no social gradient for screening participation.
Early detection of colon cancer
In all, 45.4% of women and 24.8% of men
aged between 50 and 54 years received a
test strip for detecting blood in the stool
(haemoccult test) for the purpose of early
detection of colon cancer (. Tab. 4) during the last 12 months before the interview. The majority of interviewed women and men stated that they submitted this
test strip with the required stool samples
for examination (84.8%). There is no significant influence of the SES on testing behaviour either for men or for women in
this age group.
From the age of 55 years, the haemoccult test is recommended at an interval of 2 years for those who do not wish
an early-detection colonoscopy offered
from that age. Overall, 54.2% of women
and 51.6% of men aged 55 years and older indicated that they received the test
4 |
within the 2 years preceding the interview (. Tab. 4). Almost all of them subsequently submitted the test strip for examination (96.0%). Among women, there
is an influence of age on the frequency of
participation: with increasing age, fewer women participate. When stratified by
age groups, there is no social gradient in
participation for both women and men.
From the age of 55 years, policyholders
are entitled to preventive colonoscopies.
In case of normal results, they are entitled to a repeat colonoscopy after 10 years.
Colonoscopies are carried out both as part
of cancer screening tests (early-detection
colonoscopy) and also to clarify concrete
cases of suspected disease or as part of
aftercare services. However, DEGS1 did
not ask why the last colonoscopy was undertaken. This means that whereas the
DEGS1 data can be used to describe overall the degree to which people make use
of colonoscopies for the target group of
those aged 55 years and over, this is not
the case for the subset of early-detection
colonoscopies. More than half of women (55.4%) and men (54.1%) eligible for
the service had a colonoscopy within the
last 10 years (see . Tab. 4). Women and
men aged between 55 and 59 years had
at least one colonoscopy (women 47.2%,
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
men 44.9%). One possible reason is that
they had just reached the age of eligibility. There is no clear gradient with regard
to SES.
Early detection of cervical cancer
Every second woman from the age of
20 years (52.8%) had a cervical smear test
for early detection of cervical cancer within the 12 months preceding the interview.
Women aged between 40 and 49 years
had the highest participation rate (60.7%),
whereas the lowest rate was found among
women aged 70 years and older (35.5%;
. Tab. 5). A significant influence of the
SES is present: 30- to 59-year-old women with a low SES show lower participation rates in cancer screening (within the
12 months prior to the interview) than
women with a high SES.
Early detection of breast cancer
Almost two thirds of women from the
age of 30 years (62.1%) reported that they
had undergone a clinical breast examination in the 12 months before the interview. The highest participation rates were
observed for women in the age groups of
40–49 and 50–59 years (69.9% and 69.1%,
respectively), the lowest for women aged
70 years and older (44.9%; . Tab. 5). SES
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
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Men
Total
Women
Men
Women
Total
Low
Medium
High
Total
Low
Medium
High
Total
Low
Medium
High
Total
Low
Medium
High
Total
Low
Medium
High
Total
Low
Medium
High
23.3 (17.8–29.9)
6.4 (2.0–19.2)
11.7 (7.9–16.9)
16.8 (11.1–24.8)
12.6 (8.9–17.6)
2.5 (03–16.4)
14.1 (9.0–21.6)
13.9 (7.9–23.2)
17.9 (14.3–22.1)
35–39
SocioecoAge group in years
nomic status
27.8 (24.2–31.7)
18.6 (10.4–31.0)
25.8 (21.6–30.6)
42.9 (35.0–51.2)
19.6 (16.1–23.6)
12.4 (6.6–22.0)
22.3 (16.9–28.8)
19.1 (14.2–25.2)
23.6 (21.0–26.5)
40–49
55–59
26.4 (22.9–30.2)
21.9 (14.5–31.7)
25.6 (21.8–29.8)
33.6 (26.7–41.2)
23.0 (19.7–26.6)
17.9 (11.0–27.8)
22.8 (18.5–27.8)
28.4 (21.7–36.2)
24.7 (22.1–27.4)
45.4 (40.3–50.7)
62.5 (56.5–68.3)
44.0 (29.9–59.1)
55. 8 (39.4–71.1)
43.5 (36.9–50.3)
61.4 (53.5–68.8)
53.7 (43.0–64.0)
69.3 (56.6–79.6)
24.8 (20.2–30.1)
50.3 (44.4–56.3)
17.8 (9.6–30.6)
44.1(29.8–59.5)
25.4 (19.2–32.7)
52.5 (43.2–61.7)
30.5 (19.9–43.6)
51.6 (39.4-63.7)
35.0 (31.3–38.8)
56.5 (52.0–61.0)
47.2 (41.3–53.1)
38.2 (24.1–54.6)
50.1 (42.7–57.5)
42.4 (31.2–54.4)
44.9 (38.7–51.3)
39.1 (26.3-53.6)
45.7 (36.4-55.2)
47.4 (36.4–58.7)
46.1 (41.4–50.8)
50–54
aFor the haemoccult test, the information given in the “Total” column refers to participants aged between 55 and 79 years
Total
Total
Colonoscopy from Women
55 years:
within the last
10 years
nunweighted =1,889
Men
Haemoccult
testa from 50 to
54 years:
within the last
12 months
nunweighted=307
from 55 years:
within the last
2 years
nunweighted =1,843
Whole-body skin
examination
from 35 years:
within the last
2 years
­nunweighted =1,667
Sex
26.5 (22.6–30.8)
21.9 (13.8–33.1)
28.1 (23.4–33.4)
27.6 (19.6–37.4)
29.0 (25.0–33.4)
23.4 (14.3–35.8)
26.4 (21.7–31.7)
38.8 (31.3 (46.9)
27.7 (24.8–30.8
54.8 (50.2–59.3)
40.5 (30.7–51.1)
59.3 (53.5–64.9)
60.0 (50.0–69.3)
48.3 (43.6–53.1)
43.4 (31.5–56.1)
48.8 (42.2–55.5)
50.3 (42.5-58.1)
51.7 (48.4–54.9)
58.3 (53.8–62.6)
51.7 (40.9–62.4)
60.2 (54.9–65.3)
61.4 (51.8–70.2)
58.5 (53.4–63.5)
55.5 (42.2-68.1)
58.1 (51.6––64.4)
61.0 (52.4–69.0)
58.4 (55.0–61.7)
60–69
22.5 (18.6–26.9)
18.9 (12.4–27.8)
22.7 (18.2–27.9)
40.8 (27.6–55.5)
28.8 (24.1–34.0)
19.4 (11.8–30.8)
28.8 (23.0–35.3)
43.7 (33.5–54.4)
25.3 (22.0–28.9)
48.6 (43.0–54.2)
43.5 (33.9–53.7)
53.3 (46.6–59.9)
41.5 (29.9–54.2)
56.6 (50.8–62.0)
48.6 (37.0–60.5)
58.2 (51.2–65.0)
64.6 (55.0–73.1)
52.2 (47.8–56.5)
57.5 (52.7–62.2)
45.6 (36.2–55.3)
63.5 (57.5–69.2)
70.8 (58.7–80.5)
55.4 (49.7–60.9)
55.4 (42.8–67.2)
52.2 (44.6–59.6)
68.7 (58.7–77.2)
56.6 (52.9–60.2)
70–79
25.8 (23.8–27.8)
19.7 (15.5–24.7)
25.2 (23.0–27.6)
36.7 (32.2–41.4)
22.9 (20.9–25.1)
16.4 (12.6–21.1)
23.4 (20.7–26.4)
27.2 (23.6–31.1)
24.4 (22.8–26.0)
54.2 (50.7–57.7)a
44.3 (37.5–51.4)
57.7 (53.7–61.6)
59.2 (52.4–65.7)
51.6 (48.4–54.9) a
45.6 (37.7–53.7)
53.1 (48.6–57.5)
54.3 (48.8-59.7)
53.0 (50.5–55.5)a
55.4 (52.6–58.2)
46.6 (39.9–53.5)
59.0 (55.7–62.3)
56.6 (50.3–62.8)
54.1 (50.8–57.3)
51.6 (43.9–59.2)
53.1 (48.7–57.4)
58.8 (52.9–64.5)
54.8 (52.5–57.0)
Total
Regular participation in cancer screening tests intended for women and men, categorised by sex, age groups and socioeconomic status (proportion in percent with 95% confidence
intervals)
Tab. 4
6 |
52.8 (51.0–54.6)
36.6 (32.4–41.1)
53.9 (51.8–56.1)
68.3 (64.3–72.0)
62.1 (60.2–64.1)
43.7 (39.2–48.4)
65.3 (62.8–67.8)
73.4 (69.5–77.0)
71.3 (68.0–74.4)
63.0 (55.2–70.3)
75.4 (71.6–78.8)
67.4 (60.8–73.4)
35.5 (30.8–40.4)
29.4 (21.2–39.1)
37.4 (31.6–43.6)
50.7 (37.5–63.9)
44.9 (40.0–49.9)
32.9 (24.4 –42.7)
50.7 (44.3–57.1)
59.0 (44.9–71.7)
–
49.6 (44.9–54.4)
38.8 (29.9–49.4)
52.1 (46.6–57.5)
57.9 (48.3–66.9)
62.2 (57.6–66.5)
49.8 (38.9–60.7)
66.0 (60.6–71.0)
67.5 (57.9–75.8)
74.9 (70.1–79.1)
64.7 (53.0–74.8)
80.1 (74.7–84.5)
70.3 (60.7–78.4)
54.8 (50.9–58.6)
35.2 (25.7–46.0)
55.5 (50.6–60.3)
67.7 (60.3–74.3)
69.1 (65.3–72.6)
55.0 (44.4–65.1)
70.9 (66.2–75.2)
75.2 (68.3–81.1)
68.5 (64.1–72.6)
61.1 (49.5–71.1)
71.6 (66.4–76.3)
65.9 (57.1–73.8)
Mammography from 50 to
69 years:
within the last 2 years
nunweighted=1,174
Breast palpation from 30
years:
within the last 12 months
nunweighted=2,340
Total
Low
Medium
High
Total
Low
Medium
High
Total
Low
Medium
High
–
59.3 (54.4–64.1)
35.9 (20.8–54.5)
60.3 (53.6–66.6)
73.6 (65.0–80.8)
58.9 (54.0–63.6)
32.1 (18.2–50.0)
60.8 (54.1–67.1)
72.3 (63.1–79.9)
–
52.3 (46.9–57.6)
43.5 (31.2–56.7)
50.7 (43.7–57.6)
67.9 (54.4–79.0)
–
60.7 (56.3–64.9)
40.2 (28.9–52.6)
62.0 (56.7–66.9)
73.7 (65.9–80.3)
69.9 (65.7–73.8)
49.9 (37.8–62.1)
72.1 (66.8–76.8)
79.2 (72.0–84.9)
–
50–59
40–49
30–39
Age group in years
Socioeconomic
status
20–29
Cervical smear from 20
years:
within the last 12 months
nunweighted =2,242
Tab. 5
Regular participation in cancer screening tests intended for women, categorised by age groups and socioeconomic status
(proportion in percent with 95% confidence intervals)
60–69
70–79
Total
Main topic
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
has a clear impact here: with the exception
of women aged 60–69 years, women with
a low SES show significantly lower participation rates in this particular screening test over the 12 months preceding the
interview than women of high SES. Between the ages of 50–69 years, women are
eligible for biennial radiological breast examinations as part of the national mammography screening programme. Mammographies can be carried out as part of a
cancer screening programme, to clear up
a concrete suspected diagnosis or as part
of aftercare. DEGS1 asked for the reason
for the last mammography to ensure that
the existing data could be used to provide
an overview of women’s participation in
mammography overall and also of participation in the national mammography
screening programme. Overall, 71.3% of
women in the target group aged between
50 and 69 years stated that they had had a
mammography within the last 24 months.
Slightly more women aged 60–69 years
were examined than in the younger age
groups (74.9% vs. 68.5%; . Tab. 5). There
is no SES gradient.
To state their reasons for participating
in their last mammography, participants
could choose from several answer categories (multiple answers were possible). The
most common reason for the last mammography (within the last 24 months) was
an invitation by the national mammography screening programme (65.4%). This
means that about half of all eligible women between 50 and 69 years of age were
reached by the national mammography
screening programme and underwent the
examination (49.2%).
Early detection of prostate cancer
Only 38.9% of eligible men from the age of
45 years underwent a palpation test within the last 12 months before the interview.
The participation rate increased with age.
Among men aged 70–79 years, the participation rate reached 55.5%. However,
the proportion of those who underwent
examination in the 12 months preceding
the interview was very low, especially for
younger men (20.2%; . Tab. 6). There is
no SES gradient.
The PSA blood test is also used for the
diagnosis of prostate carcinoma. However, an increased PSA value cannot be un-
Regular participation in cancer screening tests intended for men, categorised by age group and socioeconomic status
(proportion in percent with 95% confidence intervals)
Tab. 6
Socioeconomic status
Prostate palpation
from 45 years:
within the last 12 months
nunweighted =973
PSA valuea
from 45 years:
within the last 12 months
nunweighted =785
Total
Low
Medium
High
Total
Low
Medium
High
Age group in years
45–49
50–59
60–69
70–79
Total
20.2 (15.9–25.4)
12. 8 (6.1–25.1)
24.1 (17.8–31.9)
16.8 (10.5–25.9)
12.0 (8.4–16.9)
7.4 (1.5–29.1)
14.5 (9.4–21.7)
9.9 (5.5–17.2)
32.5 (28.7–36.6)
23.8 (16.3–33.4)
33.5 (28.3–39.0)
38.4 (30.2–47.3)
25.0 (290.9–29.6)
16.5 (9.6–27.1)
25.0 (19.2–31.9)
32.9 (25.3–41.6)
48.8 (44.4–53.2)
44.6 (31.9–58.1)
48.9 (43.1–54.7)
51.8 (43.5–60.0)
40.4 (35.9–45.0)
28.6 (18.6–41.4)
38.1 (32.5–43.9)
53.8 (45.8–61.6)
55.5 (49.9–60.9)
46.2 (33.9–59.0)
57.2 (50.7–63.4)
65.5 (55.0–74.7)
45.7 (40.3–51.3)
31.2 (21.4–43.1)
45.9 (39.1–52.9)
68.0 (58.3–76.4)
38.9 (36.5–41.4)
32.1 (26.4–38.4)
40.3 (37.1–43.7)
42.3 (37.5–47.2)
30.6 (28.2–33.1)
21.3 (16.9–26.4)
30.4 (27.1–34.0)
40.0 (35.1–45.1)
aNo examination as part of the cancer screening programme offered by statutory health insurance
equivocally attributed to prostate cancer,
as there can also be other causes such as
inflammation. Therefore, statutory health
insurance does not offer the PSA test for
early detection of prostate cancer as part
of the cancer screening programme. In
this case, men must pay for the test themselves as an individual health service [20].
However, if the palpation test result is positive, it is often followed up by a PSA analysis. In all, 30.6% of men aged 45 years
and over indicated that they had their PSA
level checked within the last 12 months.
The majority of men (89.5%) who had
undergone palpation of the prostate in
the last 12 months stated that the PSA level was also determined within that time
period. However, the two examinations
may have been performed separately and
in any order. This aspect was not covered
by DEGS1. Overall, 10.1% of men aged
45 years or over stated that the PSA level was tested but no palpation of the prostate took place (data not shown). PSA testing is clearly influenced by a person’s SES:
significantly fewer men of low SES underwent this examination than men of medium or high SES. When stratified by age,
this effect is evident only in 60- to 79-yearold men and only for the low compared to
the highest SES group. Participation in an
examination by palpation was not influenced by SES.
Discussion
Analysis of the data presented here shows
that a vast majority of adults in Germany, who are the target group of statutory
health insurance for cancer screening programmes, are aware of the recommenda-
tion to participate in such programmes.
According to these data, about two thirds
of women and less than half of the men
regularly undergo cancer screening. Participation rates in individually offered
cancer screening tests differ to a high degree. There are many reasons for this, and
they have to do, for example, with organisation (invitation to attend mammo­
graphy screening versus individuals taking the initiative to make an appointment
themselves in the case of other screening,
e.g. prostate cancer screening) and level of
awareness (skin cancer screening has only been offered by statutory health insurance since 2008). Overall more women
than men participate in cancer screening.
With increasing age, participation rates
rise, especially among men, and the difference between the sexes decreases. This
probably has to do with rising numbers
of doctor visits and a resulting increase in
participation probability [7, 8]. SES has an
influence on awareness and participation
in early-detection programmes, especially
among women. For age-stratified data, the
status effect often remains among women: more educated women with a higher
income more frequently undergo cancer
screening. Among men, status effects are
less frequent and less pronounced.
Information on adult participation
in cancer screening programmes can be
obtained from population-related interviews and from the payment data of
health insurers. Interviews have the advantage that in the analysis, information on participation can be related to
individuals. In addition, interviews permit inclusion of supplementary questions and issues related to participation
in cancer screening, for example, reasons for non-participation. On the other
hand, statements that participants make
about their own participation in screening programmes are subject to a certain
degree of uncertainty. In other surveys
on cancer screening participation rates,
such differences have also been observed
and discussed [21, 22]. A comparison of
the results on cancer screening participation from DEGS1 with other data sources
shows a good correlation with other interview data and a certain degree of deviation in prevalence when compared to
the payment data. With the exception of
the mammography, DEGS1 did not ask
the reason for participation in individual
cancer screening tests. The listed examinations are also offered free of charge for
statutory health insurance policyholders
given the relevant indication, for example, to investigate a suspected disease. In
that case, the fees charged by the attending physician are different. This can result in differences when comparing the
DEGS1 data with payment information.
For example, regular participation in
the offered biennial skin cancer screening programme is reported to be about
one quarter in DEGS1 but amounts to
about 33.3% for women and 31.9% for
men according to the payment data of
the Central Research Institute of Ambulatory Health Care in Germany [23]. In
the telephone interview “German Health
Update” 2010 conducted by the RKI
(GEDA 2010), every third person interviewed reported that they had participated in skin cancer screening before [21].
In DEGS1, about half of eligible women and men stated that they had under-
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
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Main topic
gone a colonoscopy before. In a survey of
the Lebensblicke Foundation conducted
in 2010, similar colonoscopy rates were
found [24]. However, as was the case with
DEGS1, no distinction was made based
on the reasons for the colonoscopy. In
contrast, the payment data for the period 2003–2011 suggest that only 20% of all
persons aged between 55 and 74 years had
a colonoscopy as part of cancer screening
[25]. According to DEGS1, roughly every
second woman from the age of 20 years
had a cervical smear for early detection
of cancer of the cervix. The Bertelsmann
Health Monitor showed that in 2007 just
over 50% of women had participated in
this programme (within 2 years) [26].
About 70% of eligible women reported in DEGS1 that they had had a mammography in the previous 2 years. A survey among AOK policyholders showed
an equally high participation rate (ever
participated) in the year 2007 [27]. However, in both cases the data provided referred to mammographies in general, i.e.
independently of the national mammography screening programme that was set
up in 2005. The evaluation of the mammography screening programme showed
a participation rate of 53.7% for the time
period 2008–2009 [28]. In DEGS1, just
over a third of men stated that they regularly participated in a prostate screening
test (palpation examination). Here, too,
there is relatively good correlation with
other surveys: In the Bertelsmann Health
Monitor, just over a third of men reported that they had participated in prostate
cancer screening (within 2 years) [26]. A
survey from 2004 on participation rates
in this cancer screening programme offered by statutory health insurance found
a regular yearly participation rate of 25%
[29].
The level of acceptance of these preventive measures can be estimated on the
basis of the analyses of cancer screening
participation. With the help of data collected in DEGS1, the population groups
that are aware of and regularly participate
in cancer screening programmes can be
described in more detail. However, it is also possible to identify groups who are not
as yet sufficiently informed about cancer
screening and who so far have made use
of such services infrequently or not at all.
8 |
With regular health surveys conducted as
part of health monitoring it will be possible in future to determine participation
rates and to make statements on trends,
also with respect to newly launched or recently expanded screening tests. For the
purpose of implementing the research results in practice, it is important not only to determine who is not participating
but also why they are not doing so. These
reasons were determined for skin and colon cancer screening in the GEDA 2010
telephone interviews of the RKI [21]. Indications of what type of support target
groups need to make an informed decision are important sources for health policy planning and can help to further improve participation in cancer screening
programmes.
An extension of cancer screening is
planned within the framework of the National Cancer Plan, among other measures. These plans are inspired by the relevant European guidelines [30]. Providing better information to policyholders about the benefits and risks of cancer screening as well as sending regular
letters of invitation to improve participation rates are planned. These measures
aim to strengthen cancer screening programmes and, by permitting early cancer detection, should help improve the
chances of survival of those affected and
thus reduce cancer mortality rates in the
population [18].
Corresponding address
A. Starker
Department of Epidemiology and
Health Monitoring, Robert Koch Institute
General-Pape-Str. 62–66, 12101 Berlin
Germany
[email protected]
Acknowledgements. The study was financed by
the Robert Koch Institute and the Federal Ministry of
Health.
Conflict of interest. On behalf of all authors, the corresponding author states that there are no conflicts
of interest.
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
References
1. Statistisches Bundesamt (2011) Todesursachenstatistik 2010. http://www.gbe-bund.de. Accessed
30 Oct 2012
2. Robert Koch-Institut, Gesellschaft der epidemiologischen Krebsregister (2012) Krebs in Deutschland
2007/2008. 8. Ausgabe. RKI, Berlin
3. Robert Koch-Institut (2010) Verbreitung von
Krebs­erkrankungen in Deutschland. Entwicklung der Prävalenzen zwischen 1990 und 2010.
Beiträge zur Gesundheitsberichterstattung des
Bundes. RKI, Berlin
4. Gemeinsamer Bundesausschuss (2011) Richtlinie
über die Früherkennung von Krebserkrankungen
in der Fassung vom 18. Juni 2009, zuletzt geändert
am 16. Dezember 2010, veröffentlicht im Bundes­
anzeiger Nr. 34: S 86, in Kraft getreten am 3. März
2011
5. Wilson JM, Jungner YG (1968) Principles and practices of screening for disease. World Health Organization, Geneva
6. Sozialgesetzbuch Fünftes Buch (2012) Vierter­
Abschnitt Leistungen zur Früherkennung von
Krankheiten, § 25 Gesundheitsuntersuchungen.
http://www.gesetze-im-internet.de. Accessed 30
Oct 2012
7. Scheffer S, Dauven S, Sieverding M (2006) Sozio­
demografische Unterschiede in der Teilnahme an
Krebsfrüherkennungsuntersuchungen (KFU) in
Deutschland – Eine Übersicht. Gesundheitswesen
68(3):139–146
8. Bergmann E, Kalcklösch M, Tiemann F (2005)
Health care utilisation. Initial results of the Telephone Health Survey 2003. Bundesgesund­heitsbl
Gesundheitsforsch Gesundheitsschutz 48:1365–
1373
9. Starker A, Saß AC, Ziese T (2006) Inanspruchnahme
von Gesundheits- und Krebsfrüherkennungsuntersuchungen. Wer nutzt sie (nicht) und warum? Gesundheitswesen 68(7):A125
10. Starker A, Saß AC (2007) Eigenverantwortung
+ Hausarzt = gut versorgt? Ergebnisse des Telefonischen Gesundheitssurveys 2004 zum Präventionsverhalten in Deutschland. Prävention und Gesundheitsförderung 2(Supplement 1):P124
11. Kurth BM, Lange C, Kamtsiuris P et al (2009) Health
Monitoring at the Robert Koch-Institute. Status
and perspectives. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 52(5):557–570
12. Kurth BM (2012) Das RKI-Gesundheitsmonitoring
– was es enthält und wie es genutzt werden kann.
Public Health Forum 20(76):4.e1–4.e3
13. Gößwald A, Lange M, Kamtsiuris P, Kurth BM
(2012) DEGS: German health interview and examination survey for adults. A nationwide cross-sectional and longitudinal study within the framework of health monitoring conducted by the Ro­
bert Koch-Institute. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 55:775–780
14. Scheidt-Nave C, Kamtsiuris P, Gößwald A et al
(2012) German health interview and examination
survey for adults (DEGS) – design, objectives and
implementation of the first data collection wave.
BMC Public Health 12:730
15. Kamtsiuris P, Lange M, Hoffmann R et al (2013) The
first wave of the German health interview and examination survey for adults (DEGS1). Sampling design, response, sample weights, and representativeness. Bundesgesundheitsbl Gesundheitsforsch
Gesundheitsschutz 56:620–630
16. Robert Koch-Institut (2009) DEGS – Studie zur Gesundheit Erwachsener in Deutschland. Projektbe­
schreibung. Beiträge zur Gesundheitsberichterstattung des Bundes. RKI, Berlin
17. Gößwald A, Lange M, Dölle R, Hölling H (2013) The
first wave of the German health interview and examination survey for adults (DEGS1). Participant
recruitment, fieldwork, and quality management.
Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 56:611–619
18. Kraywinkel K, Bertz J, Laudi A et al (2012) Epidemiologie und Früherkennung häufiger Krebserkrankungen in Deutschland. GBE kompakt. 3(4).
RKI (Hrsg), Berlin. http://www.rki.de/gbe-kompakt.
Accessed 06 Aug 2012
19. Lampert T, Kroll L, Müters S, Stolzenberg H (2013)
Measurement of socioeconomic status in the German health interview and examination survey for
adults (DEGSS1). Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 56:631–636
20. Medizinische Dienst des Spitzenverbandes Bund
der Krankenkassen e.V. (2012) PSA-Test zur Früherkennung von Prostatakrebs. http://www.igelmonitor.de. Accessed 04 Dec 2012
21. Starker A, Bertz J, Saß AC (2012) Inanspruchnahme
von Krebsfrüherkennungsuntersuchungen. In:
Robert Koch-Institut (Hrsg) Daten und Fakten:
Ergebnisse der Studie „Gesundheit in Deutschland
aktuell 2010” Beiträge zur Gesundheitsberichterstattung des Bundes. RKI, Berlin
22. Streich W, Hellmeier W (2009) Teilnahme an Vorsorge- und Früherkennungsuntersuchungen. NRW
Kurz und informativ, April 2009. http://www.lzg.
gc.nrw.de/_media/pdf/gesundheitberichteda­ten/
nrw-kurz-und-informativ/teilnahme-vorsorgefrueherkennung_0905.pdf. Accessed 30 Oct 2012
23. Zentralinstitut für die kassenärztliche Versorgung
in der Bundesrepublik, Altenhofen L (2012a) Teilnahme an gesetzlichen Früherkennungsuntersuchungen im Jahr 2011. Unveröffentlichte Sonderauswertung für das Robert Koch-Institut. Accessed
15 Oct 2012
24. Stiftung Lebensblicke, Wuppermann D (2011) Aktueller Wissensstand der Bevölkerung zur Darmkrebsvorsorge. Persönliche Mitteilung über unveröffentlichte Auswertungen. Accessed 09 July
2011
25. Zentralinstitut für die kassenärztliche Versorgung
in der Bundesrepublik (2012) Teilnahme an gesetzlichen Früherkennungsuntersuchungen und
an Beratungen zur Prävention des Darmkrebs im
Jahr 2011. http://www.zi.de/cms/fileadmin/images/content/PDFs_alle/Beteiligungsraten_2011_
Deutschland_erw.pdf Accessed 30 Oct 2012
26. Koch K, Scheibler F (2007) Einstellungen und Informationsstand zur Früherkennung: Informiert und
doch getäuscht. In: Böcken J, Braun B, Amhof R
(Hrsg) Gesundheitsmonitor 2007 Gesundheitsversorgung und Gestaltungsoptionen aus der Perspektive von Bevölkerung und Ärzten. Bertelsmann
Stiftung, Gütersloh, S 178–200
27. Zok K (2007) Wahrnehmung und Akzeptanz von
Früherkennungsuntersuchungen. Ergebnisse ei­ner
Repräsentativ-Umfrage unter GKV-Versicherten.
WIdO Monitor 03/2007. http://www.wido.de/fileadmin/wido/downloads/pdf_wido_monitor/wido_mon_3-07_0108.pdf. Accessed 30 Oct 2012
28. Kooperationsgemeinschaft Mammographie
(2012) Evaluationsbericht 2008–2009. Ergebnisse
des Mammographie-Screening-Programms in
Deutschland. Kooperationsgemeinschaft Mammographie, Berlin
29. Sieverding M, Matterne U, Ciccarello L et al (2008)
Prostatakarzinomfrüherkennung in Deutschland.
Untersuchung einer repräsentativen Stichprobe.
Urologe 47(9):1233–1238
30. Bundesministerium für Gesundheit (2012)
Fortschritte für die Krebsbekämpfung – Kabinett
beschließt das Gesetz zur Weiterentwicklung der
Krebsfrüherkennung und zur Qualitätssicherung
durch klinische Krebsregister. Pressemitteilung
vom 22. August 2012. http://www.bundesgesundheitsministerium.de/fileadmin/dateien/Pressemitteilungen/2012/2012_03/120822_PM_61_
Kabinett_beschliesst_das_Gesetz_zur_Weiterentwicklung_der_Krebsfrueherkennung.pdf. Accessed 10 Sept 2012
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 5/6 · 2013
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